Human Reproduction Vol.16, No.6 pp.

13011304, 2001

Guidelines for counselling in infertility: outline version

J.Boivin1,16, T.C.Appleton2, P.Baetens3, J.Baron4, J.Bitzer5, E.Corrigan6, K.R.Daniels7,
J.Darwish8, D.Guerra-Diaz9, M.Hammar10, A.McWhinnie11, B.Strauss12, P.Thorn13,
T.Wischmann14 and H.Kentenich15
1School of Psychology, Cardiff University, Cardiff, Wales, 2Department of Obstetrics and Gynaecology, Cambridge University,
Cambridge, UK, 3Centre for Reproductive Medicine, Academic Hospital, Dutch-speaking Free University of Brussels, Belgium,
4Midland Fertility Services, Birmingham, UK, 5University Frauenklinik, Basel, Switzerland, 6Centre for Reproductive Medicine,
University of Bristol, UK, 7Department of Social Work, University of Canterbury, Christchurch, New Zealand, 8Service de
Psychiatrie de Liaison and Unite de Medecine de la Reproduction, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland,
9Servicio de Medicina Psicosomatica, Instituto Universitario Dexeus, Barcelona, Spain, 10Fertilitetscentrum, Carlanderska
sjukhemmet, Goteberg, Sweden, 11University of Dundee, Scotland, UK, 12Department of Medical Psychology, Friedrich-SchillerUniversity of Jena, Jena, Germany, 13Department of Social Work, Protestant University of Applied Sciences, Darmstadt,
14Department of Medical Psychology, Heidelberg University Hospital, Heidelberg and 15DRK Frauenklinik, Berlin, Germany
16To

whom correspondence should be addressed. E-mail: Boivin@cardiff.ac.uk

The Guidelines for Counselling in Infertility describe the purpose, objectives, typical issues and communication
skills involved in providing psychosocial care to individuals using fertility services. The Guidelines are presented
in six sections. The first section describes how infertility consultations differ from other medical consultations in
obstetrics and gynaecology, whereas the second section addresses fundamental issues in counselling, such as what
is counselling in infertility, who should counsel and who is likely to need counselling. Section 3 focuses on how to
integrate patient-centred care and counselling into routine medical treatment and section 4 highlights some of the
special situations which can provoke the need for counselling (e.g. facing the end of treatment, sexual problems).
Section 5 deals exclusively with third party reproduction and the psychosocial implications of gamete donation,
surrogacy and adoption for heterosexual and gay couples and single women without partners. The final section of
the Guidelines is concerned with psychosocial services that can be used to supplement counselling services in
fertility clinics: written psychosocial information, telephone counselling, self-help groups and professionally facilitated
group work. This paper summarizes the different sections of the Guidelines and describes how to obtain the
complete text of the Guidelines for Counselling in Infertility.
Key words: counselling/guidelines/infertility/psychology

Introduction
The infertility consultation differs from other symptom- or
disease-orientated consultations in obstetrics and gynaecology
through the following characteristics (Section 1, H.Kentenich):
(a) The central focus of the consultation is an unfulfilled wish
or goal in life. As a result, the counsellors are not dealing
so much with the objective of finding a diagnosis, but far
more with subjectively defined suffering determined by
various personal and psychosocial features.
(b) The wish for a child aims to create a not-yet-existing third
person who cannot be included in the decision-making
process or the treatment. There are specific ethical issues
resulting from the absence of the third person. Some of
the essential issues that must be considered include the
best interests of the child, the family environment into
which the child conceived by the use of assisted reproduction will be born, and any possible contradictions and
European Society of Human Reproduction and Embryology

conflicts between the wishes of the patients and the

presumed interests of the child.
(c) The treatment of the unfulfilled wish for a child very
frequently involves a cycle of repeated interventions that
can be successful, but often are not. This long-lasting
process creates specific emotional stresses accompanied
by disappointment and possible desperation.
(d) Diagnostic procedures and medical treatment in infertility
have an important impact on the intimate life of the
patients. Therefore, the couples relationship dynamics,
sexuality and ability to cope with the psychological
and emotional effects caused by this process must be
considered in addition to the course of treatment and
future treatment options.
Fertility clinics should therefore aim to address the psychosocial and emotional needs of their patients as well as their
medical needs. This aim can be achieved by ensuring that
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Table I. Objectives when using adjunct (additional) psychosocial services

Table II. Counselling objectives in special situations

psychosocial care is provided throughout the treatment

experience. To help fertility clinics meet these objectives, we
have developed the Guidelines for Counselling in Infertility.
These Guidelines show how patient-centred care can be integrated into the day-to-day activities of the medical team and how
professional counselling can be used to meet any extraordinary
patient need.
The Guidelines for Counselling in Infertility have been
discussed and written collaboratively with individuals from
many countries. It is hoped this team effort has generated a
set of Guidelines that encompass the psychosocial issues faced
by infertile couples and the way in which counsellors from
different countries can address them. The Guidelines are
intended for both medical staff and mental health professionals
and it is hoped that information contained therein will help
both groups to maintain good practice with regard to psychosocial care for infertile couples. Naturally, the Guidelines will
require revision as new issues emerge and/or some issues
become more or less important. Already some topics, for
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example preimplantation genetic diagnosis, which were

excluded from this version are planned for the revision of the
Guidelines. It is also hoped that the Guidelines can be revised
in light of feedback from the community of professionals
working with infertile individuals.
The complete Guidelines for Counselling in Infertility could
not be included in the journal, and what follows is therefore
a summary. However, the full text can be accessed through
the ESHRE website (http://www.eshre.com). In the following
summary, citations in parentheses refer to specific authors and
sections of the complete Guidelines.
Outline
The infertility medical experience can be thought of as a 10step recurrent cycle that the patient can enter, exit and re-enter
at any point (see Section 3, J.Bitzer). The process begins with
the initiation of the therapeutic relationship and ends with the
outcome and evaluation of a given treatment. Each step in the

Guidelines for counselling in infertility

Table III. Counselling objectives in third party reproduction

Table IV. Additional objectives for counselling in social infertility

cycle will have a purpose and a set of objectives and each

step will present typical issues and will require specific
communication skills. These aspects of the consultation are
usually addressed from a medical perspective. However, they
can also be addressed from a psychosocial perspective. For
example, the purpose of the first meeting with patients is to
provide a helpful and competent environment, with the objectives being to ensure that patients feel understood, respected
and reassured. The communication skills involved at this stage
might be as basic as remembering who the patient is
(e.g. their names, professions) or as complex as detecting the
negative feelings that patients are unable to express. Some of
the typical issues encountered in a first meeting are that the
team environment does not allow patients to overcome feelings
of embarrassment and shame, or that it treats the patient
anonymously. This example illustrates how psychosocial care
can be integrated in the first step of the medical cycle, that is,
the initial meeting. The Guidelines describe how such patientcentred care can be integrated into other steps of the medical

process (e.g. considering treatment options, evaluating treatment outcome).

The physician plays an important part in ensuring that
psychosocial care is integrated into patient care through his/
her relationship to the patient as well as the entire team
(see Section 2.4, H.Kentenich). Depending on past training,
physicians can also be involved in the counselling of infertility
patients, though for the most part physicians will refer patients
to trained counsellors for this aspect of their treatment experience. In any case, physicians should have good communication
skills and a basic knowledge of counselling.
The nature of psychosocial care will vary from clinic to
clinic, depending on the countrys legal and social framework.
Despite these potential sources of differences, it is possible to
identify two broad types of psychosocial care that have been
the subject of discussion (see Section 2.1, B.Strauss and
J.Boivin). Patient-centred care is the psychosocial care provided as part of routine services at the clinic. Counselling, on
the other hand, involves the use of psychological interventions
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based on specific theoretical frameworks. Whereas patientcentred care is expected from all members of the medical team
at all times, counselling is typically delivered by someone
having received training in the mental health professions (e.g.
psychology, social work, counselling). It is important to have
both types of care available.
Patient-centred care will vary from answering questions to
providing support after distressing events such as a negative
pregnancy test. Clinics can increase their overall level of
patient-centred care by providing other non-professional services that may be useful to patients. Table I presents some of
the objectives and typical issues that might arise from using
these additional psychosocial services (see Section 6.1,
J.Boivin, Section, 6.2, 6.3, P.Thorn).
Counselling, on the other hand, aims to address the extraordinary needs of some patients (see Section 2.1, B.Strauss and
J.Boivin). Counselling might include individual and couple
therapy and/or professionally facilitated support groups. The
content of counselling may differ depending on the patient
and the treatment choice but will usually involve at least some
form of information and implication counselling, support or
therapeutic counselling. Information and implication counselling might focus on ensuring that individuals understand the
different psychosocial issues involved in their treatment choice
whereas therapeutic counselling might involve an understanding of the emotional consequences of childlessness. A key
difference between patient-centred care and counselling is the
counsellors level of training (see Section 2.2, E.Corrigan,
K.Daniels and P.Thorn). Guidance concerning qualifications for
counsellors working with infertile patients has been provided by
different organizations and/or governmental bodies. While an
agreed set of criteria for who should counsel has yet to
emerge, at the minimum counsellors should have received
training in one of the mental health professions (e.g. psychology, social work, counselling) as well as training in the
medical aspects of reproduction. As noted previously, all
staff can and should provide patient-centred care but only
professionally trained individuals can provide counselling.
The Guidelines describe some of the practical issues that
need to be addressed between counsellors and the team with
whom they work. These issues might include whether the
counsellor will be involved in the assessment and/or screening
of patients for treatment and whether counsellors will work
independently or within the clinic environment. Other issues
may arise when, for example, the treating physician is also
providing the counselling.
A review of the literature identifies three populations who
might benefit from and/or require counselling. The first group
represents the majority of patients seen by the counsellor

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patients who experience very high levels of distress (see

Section 2.3, J.Boivin). The distress may be manifested in
different ways (e.g. depression, anxiety), but is generally
perceived by the patient as being overwhelming and difficult
to manage. While highly distressed patients form a significant
proportion of those using professional counselling, they make
up only ~20% of all infertility patients. The purpose and
objective of counselling in such cases will vary depending on
the source of distress.
The Guidelines describe some of the personal characteristics
that may place someone at risk for high distress (e.g. preexisting depression) and some of the situations that may trigger
high distress (e.g. failed treatment, fetal reduction). Table II
describes some of the special situations which may lead to
high distress and some of the objectives and typical issues
which arise from counselling in these situations.
The second group of patients who use counselling are those
couples requiring donated gametes, surrogacy and/or adoption
to achieve parenthood. So-called third-party reproduction is
thought to provoke psychological and emotional issues that
go beyond the counselling issues involved in treatments not
requiring a third party. Table III summarizes some of the
objectives and typical issues that arise from counselling with
individuals requiring a third party for family building.
The final group of patients who benefit from counselling
are those who seek fertility services because of their social
circumstances rather than their medical status. Single and
lesbian women who use donated spermatozoa or gay men who
use surrogacy fall in this category. While these individuals
will also face the general issues described in Table III for third
party reproduction, they also face issues that are specific to
social infertility. Table IV describes some of the objectives
and typical issues that arise in counselling with this group
of patients.
Conclusions
Good practice in infertility clinics encompasses more than
medical care. Clinics need to be prepared to take into account
and deal with the psychosocial issues that confront couples
who use their services. The basic aim of any counselling
(whether patient-centred or professional) is to ensure that
patients understand the implications of their treatment choice,
receive sufficient emotional support and can cope in a healthy
way with the consequences of the infertility experience. A
more holistic approach to patient care is believed to improve
health outcomes, increase patient and team satisfaction, reduce
negative psychosocial reactions and help patients better come
to terms with their experiences.